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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600707
Report Date: 07/12/2023
Date Signed: 07/12/2023 01:17:12 PM

Document Has Been Signed on 07/12/2023 01:17 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:MILLBRAE FAMILY CARE HOMEFACILITY NUMBER:
415600707
ADMINISTRATOR:DE LOS REYES ANDAYA, JULITFACILITY TYPE:
740
ADDRESS:487 ANITA DRIVETELEPHONE:
(650) 692-1297
CITY:MILLBRAESTATE: CAZIP CODE:
94030
CAPACITY: 6CENSUS: 5DATE:
07/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Wilma De Guzman TIME COMPLETED:
01:30 PM
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LPA Audrey Jeung toured facility and grounds. There are no accessible bodies of water or fire safety hazards observed. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable room temperature is maintained, and lighting is sufficient for safety. Carbon monoxide detector is tested and operable. First-aid kit is maintained and complete.
This facility is one level, with 5 client bedrooms, 2 full bathrooms, 1 half bathroom, kitchen, living/dining room, staff room, and attached 2-car garage, where the washer and dryer and an enclosed room are located; the garage room is used as sleeping room for staff, and has an exit door. Staff room has two beds. The backyard is paved and enclosed by a stone wall in the back and wood fence on the sides. There is a
storage shed in backyard. Medications are stored in locked kitchen cabinet and chemicals and cleaners are stored in locked garage cabinet.
An updated Disaster and Mass Casualty Plan is posted, and copy is given to LPA. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed.
Julita Andaya and Wilma De Guzman are certified RCFE administrators (x 2/25 & 5/24) that oversee facility operations.
Client records and Staff training records will be reviewed at a later date.

The following forms are provided and shall be completed and returned to CCL by 7/28/23:
• LIC 308 Designation of Administrative Responsibility, including Board resolution
• LIC 309 Administrative Organization
• LIC 500 Personnel Report
• LIC 610 Emergency Disaster Plan (signed and dated)
• Infection Control Plan (signed and dated)
• Proof of liability insurance for $1 million per incident and $3 million in annual aggregate
• Control of property/valid lease agreement
Deficiencies of the CA Code of Regulations, Title 22 are cited on a following page. Also, see 3 Advisory Notes issued.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE: DATE: 07/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/12/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/12/2023 01:17 PM - It Cannot Be Edited


Created By: Audrey Jeung On 07/12/2023 at 12:24 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: MILLBRAE FAMILY CARE HOME
FACILITY NUMBER: 415600707

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
MAINTENANCE AND OPERATION

The facility shall be clean, safe, sanitary and in good repair at all times.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, as wood fence boards, chairs, commodes, building equipment, dresser, are stored in back and side yards. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/26/2023
Plan of Correction
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Back and side yards will be cleared of wood and furnishings. Proof of correction to be submitted to CCLD BY DUE DATE.
Type B
Section Cited
CCR
87411(C)(1)
PERSONNEL REQUIREMENTS - GENERAL
Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on review of staff records, the licensee did not comply with the section cited above , as 3 out of 7 staff do not have proof of current first-aid training, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/26/2023
Plan of Correction
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Proof of current first-aid training for staff #3, #5, #6 will be sent to CCLD BY DUE DATE
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Cara Smith
LICENSING EVALUATOR NAME:Audrey Jeung
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2023


LIC809 (FAS) - (06/04)
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